Optimal left ventricular endocardial pacing sites for cardiac resynchronization therapy in patients with ischemic cardiomyopathy

David D. Spragg, Jun Dong, Barry J. Fetics, Robert Helm, Joseph E. Marine, Alan Cheng, Charles Henrikson, David A. Kass, Ronald D. Berger

Research output: Contribution to journalArticle

139 Citations (Scopus)

Abstract

Objectives We sought to investigate the impact of left ventricular (LV) pacing site on mechanical response to cardiac resynchronization therapy (CRT) in patients with ischemic cardiomyopathy (ICM). Background CRT reduces morbidity and mortality in patients with dyssynchronous LV failure; however, variability in response, particularly in ICM patients, poses ongoing challenges. Endocardial biventricular (BiV) stimulation may provide more flexibility in LV site selection and yield more natural transmural activation patterns. Whether this applies to ICM and whether optimal LV endocardial pacing locations vary among ICM patients remain unknown. Methods Peak rate of LV pressure increase (dP/dtmax) was measured at baseline, during VDD pacing at the right ventricular apex, and during BiV pacing from the right ventricular apex and 51 ± 14 different LV endocardial sites in patients with ICM (n = 11). Seven patients already had an epicardial LV lead (CRT) in place, allowing comparison of epicardial BiV stimulation with that using an endocardial site directly transmural to the CRT-coronary sinus lead tip. Electroanatomic 3-dimensional maps with color-coded dP/dtmax response defined optimal pacing regions delivering max. Results Endocardial BiV pacing improved dP/dtmax over right ventricular apex pacing in all patients (mean increase 241 ± 38 mm Hg/s; p <0.0001). In patients with pre-existing CRT leads, LV endocardial versus epicardial pacing at transmural sites yielded equivalent dP/dtmax values. However, dP/dtmax at the best endocardial site exceeded that achieved with the pre-implanted CRT device (mean increase 111 ± 25 mm Hg/s; p = 0.004). An average of ∼2 optimal endocardial sites were identified for each patient, located at the extreme basal lateral wall (8 of 11 patients) and other regions (9 of 11). Standard mid-LV free wall pacing yielded suboptimal LV function in 73% of patients. Optimal pacing sites were typically located in LV territories remote (9.3 ± 3.6 cm) from the infarct zone. Conclusions CRT delivered at best LV endocardial sites is more effective than via pre-implanted coronary sinus lead pacing. The location of optimal LV endocardial pacing varies among patients with ICM, and individual tailoring may improve CRT efficacy in such patients.

Original languageEnglish (US)
Pages (from-to)774-781
Number of pages8
JournalJournal of the American College of Cardiology
Volume56
Issue number10
DOIs
StatePublished - Aug 31 2010
Externally publishedYes

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Cardiac Resynchronization Therapy
Cardiomyopathies
Coronary Sinus
Cardiac Resynchronization Therapy Devices
Ventricular Pressure
Left Ventricular Function

Keywords

  • cardiac resynchronization therapy
  • heart failure
  • pacing

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Optimal left ventricular endocardial pacing sites for cardiac resynchronization therapy in patients with ischemic cardiomyopathy. / Spragg, David D.; Dong, Jun; Fetics, Barry J.; Helm, Robert; Marine, Joseph E.; Cheng, Alan; Henrikson, Charles; Kass, David A.; Berger, Ronald D.

In: Journal of the American College of Cardiology, Vol. 56, No. 10, 31.08.2010, p. 774-781.

Research output: Contribution to journalArticle

Spragg, David D. ; Dong, Jun ; Fetics, Barry J. ; Helm, Robert ; Marine, Joseph E. ; Cheng, Alan ; Henrikson, Charles ; Kass, David A. ; Berger, Ronald D. / Optimal left ventricular endocardial pacing sites for cardiac resynchronization therapy in patients with ischemic cardiomyopathy. In: Journal of the American College of Cardiology. 2010 ; Vol. 56, No. 10. pp. 774-781.
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abstract = "Objectives We sought to investigate the impact of left ventricular (LV) pacing site on mechanical response to cardiac resynchronization therapy (CRT) in patients with ischemic cardiomyopathy (ICM). Background CRT reduces morbidity and mortality in patients with dyssynchronous LV failure; however, variability in response, particularly in ICM patients, poses ongoing challenges. Endocardial biventricular (BiV) stimulation may provide more flexibility in LV site selection and yield more natural transmural activation patterns. Whether this applies to ICM and whether optimal LV endocardial pacing locations vary among ICM patients remain unknown. Methods Peak rate of LV pressure increase (dP/dtmax) was measured at baseline, during VDD pacing at the right ventricular apex, and during BiV pacing from the right ventricular apex and 51 ± 14 different LV endocardial sites in patients with ICM (n = 11). Seven patients already had an epicardial LV lead (CRT) in place, allowing comparison of epicardial BiV stimulation with that using an endocardial site directly transmural to the CRT-coronary sinus lead tip. Electroanatomic 3-dimensional maps with color-coded dP/dtmax response defined optimal pacing regions delivering max. Results Endocardial BiV pacing improved dP/dtmax over right ventricular apex pacing in all patients (mean increase 241 ± 38 mm Hg/s; p <0.0001). In patients with pre-existing CRT leads, LV endocardial versus epicardial pacing at transmural sites yielded equivalent dP/dtmax values. However, dP/dtmax at the best endocardial site exceeded that achieved with the pre-implanted CRT device (mean increase 111 ± 25 mm Hg/s; p = 0.004). An average of ∼2 optimal endocardial sites were identified for each patient, located at the extreme basal lateral wall (8 of 11 patients) and other regions (9 of 11). Standard mid-LV free wall pacing yielded suboptimal LV function in 73{\%} of patients. Optimal pacing sites were typically located in LV territories remote (9.3 ± 3.6 cm) from the infarct zone. Conclusions CRT delivered at best LV endocardial sites is more effective than via pre-implanted coronary sinus lead pacing. The location of optimal LV endocardial pacing varies among patients with ICM, and individual tailoring may improve CRT efficacy in such patients.",
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AU - Dong, Jun

AU - Fetics, Barry J.

AU - Helm, Robert

AU - Marine, Joseph E.

AU - Cheng, Alan

AU - Henrikson, Charles

AU - Kass, David A.

AU - Berger, Ronald D.

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N2 - Objectives We sought to investigate the impact of left ventricular (LV) pacing site on mechanical response to cardiac resynchronization therapy (CRT) in patients with ischemic cardiomyopathy (ICM). Background CRT reduces morbidity and mortality in patients with dyssynchronous LV failure; however, variability in response, particularly in ICM patients, poses ongoing challenges. Endocardial biventricular (BiV) stimulation may provide more flexibility in LV site selection and yield more natural transmural activation patterns. Whether this applies to ICM and whether optimal LV endocardial pacing locations vary among ICM patients remain unknown. Methods Peak rate of LV pressure increase (dP/dtmax) was measured at baseline, during VDD pacing at the right ventricular apex, and during BiV pacing from the right ventricular apex and 51 ± 14 different LV endocardial sites in patients with ICM (n = 11). Seven patients already had an epicardial LV lead (CRT) in place, allowing comparison of epicardial BiV stimulation with that using an endocardial site directly transmural to the CRT-coronary sinus lead tip. Electroanatomic 3-dimensional maps with color-coded dP/dtmax response defined optimal pacing regions delivering max. Results Endocardial BiV pacing improved dP/dtmax over right ventricular apex pacing in all patients (mean increase 241 ± 38 mm Hg/s; p <0.0001). In patients with pre-existing CRT leads, LV endocardial versus epicardial pacing at transmural sites yielded equivalent dP/dtmax values. However, dP/dtmax at the best endocardial site exceeded that achieved with the pre-implanted CRT device (mean increase 111 ± 25 mm Hg/s; p = 0.004). An average of ∼2 optimal endocardial sites were identified for each patient, located at the extreme basal lateral wall (8 of 11 patients) and other regions (9 of 11). Standard mid-LV free wall pacing yielded suboptimal LV function in 73% of patients. Optimal pacing sites were typically located in LV territories remote (9.3 ± 3.6 cm) from the infarct zone. Conclusions CRT delivered at best LV endocardial sites is more effective than via pre-implanted coronary sinus lead pacing. The location of optimal LV endocardial pacing varies among patients with ICM, and individual tailoring may improve CRT efficacy in such patients.

AB - Objectives We sought to investigate the impact of left ventricular (LV) pacing site on mechanical response to cardiac resynchronization therapy (CRT) in patients with ischemic cardiomyopathy (ICM). Background CRT reduces morbidity and mortality in patients with dyssynchronous LV failure; however, variability in response, particularly in ICM patients, poses ongoing challenges. Endocardial biventricular (BiV) stimulation may provide more flexibility in LV site selection and yield more natural transmural activation patterns. Whether this applies to ICM and whether optimal LV endocardial pacing locations vary among ICM patients remain unknown. Methods Peak rate of LV pressure increase (dP/dtmax) was measured at baseline, during VDD pacing at the right ventricular apex, and during BiV pacing from the right ventricular apex and 51 ± 14 different LV endocardial sites in patients with ICM (n = 11). Seven patients already had an epicardial LV lead (CRT) in place, allowing comparison of epicardial BiV stimulation with that using an endocardial site directly transmural to the CRT-coronary sinus lead tip. Electroanatomic 3-dimensional maps with color-coded dP/dtmax response defined optimal pacing regions delivering max. Results Endocardial BiV pacing improved dP/dtmax over right ventricular apex pacing in all patients (mean increase 241 ± 38 mm Hg/s; p <0.0001). In patients with pre-existing CRT leads, LV endocardial versus epicardial pacing at transmural sites yielded equivalent dP/dtmax values. However, dP/dtmax at the best endocardial site exceeded that achieved with the pre-implanted CRT device (mean increase 111 ± 25 mm Hg/s; p = 0.004). An average of ∼2 optimal endocardial sites were identified for each patient, located at the extreme basal lateral wall (8 of 11 patients) and other regions (9 of 11). Standard mid-LV free wall pacing yielded suboptimal LV function in 73% of patients. Optimal pacing sites were typically located in LV territories remote (9.3 ± 3.6 cm) from the infarct zone. Conclusions CRT delivered at best LV endocardial sites is more effective than via pre-implanted coronary sinus lead pacing. The location of optimal LV endocardial pacing varies among patients with ICM, and individual tailoring may improve CRT efficacy in such patients.

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